Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1787 Date: February 3, 2017

Transcription

1 anual ystem Pub One-Time Notification epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 1787 ate: ebruary 3, 2017 hange Request 9893 UBJT: New ommon orking ile () edicare econdary Payer (P) Type for Liability edicare et-side rrangements (Ls) and No-ault edicare et-side rrangements (Ns). URY O NG: This change request (R) identifies the roles the edicare dministrative ontractors ( s), urable edical quipment s ( s), shared systems, and ommon orking ile () will have for creating Liability nsurance edicare et-side rrangement (L) or No-ault nsurance edicare et-side rrangement (N) records on and process edicare econdary Payer (P) claims accordingly with an open set aside P record on. T T: July 1, ,, and nalysis and esign; October 1, ,, and oding and Testing *Unless otherwise specified, the effective date is the date of service. PLNTTON T: July 3, ,, and nalysis and esign; October 2, ,, and oding and Testing isclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTRUTON: (N/ if manual is not updated) R=R, N=N, =LT-Only One Per Row. R/N/ N/ PTR / TON / UBTON / TTL N/. UNNG: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.. TTNT: One Time Notification

2 ttachment - One-Time Notification Pub Transmittal: 1787 ate: ebruary 3, 2017 hange Request: 9893 UBJT: New ommon orking ile () edicare econdary Payer (P) Type for Liability edicare et-side rrangements (Ls) and No-ault edicare et-side rrangements (Ns) T T: July 1, ,, and nalysis and esign; October 1, ,, and oding and Testing *Unless otherwise specified, the effective date is the date of service. PLNTTON T: July 3, ,, and nalysis and esign; October 2, ,, and oding and Testing. GNRL NORTON. Background: To comply with the Government ccountability Office final report entitled P dditional teps are Needed to mprove Program ffectiveness for Non Group ealth Plans (GO ), the enters for edicare & edicaid ervices () will establish two new set-aide processes: Liability edicare et-aside rrangement (L) and a No-ault edicare et-aside rrangement (N). n L or N is an allocation of funds from a liability or an auto/no-fault related settlement, judgment, award, or other payment that is used to pay for an individual s future medical and/or future prescription drug treatment expenses that would otherwise be reimbursable by edicare. This R: 1) addresses the policies, procedures, and system updates required to create and utilize an L and N P record, similar to a orkers ompensation edicare et-side rrangement () P record and 2) instructs the s and shared systems when to deny payment for items or services that should be paid from an L or N fund. B. Policy: Pursuant to 42 U y(b)(2) and 1862(b)(2)()(ii) of the ocial ecurity ct, edicare is precluded from making payment when payment has been made or can reasonably be expected to be made under a workers compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance." edicare does not make claims payment for future medical expenses associated with a settlement, judgment, award, or other payment because payment has been made for such items or services through use of L or N funds. owever, Liability and No-ault P claims that do not have a will continue to be processed under current P claims processing instructions.. BUN RQURNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility hared- ystem aintainers The L and N P records shall only be applied to if a Liability (L) or No-ault/uto () NGP P record already exists on the P uxiliary ile. B BR, P

3 hared- ystem aintainers B The Liability (L) or No-ault/uto () NGP P record on shall have a termination date prior to a L and N record being created The L and N effective date shall be the day after the Liability (L) or No-ault/uto () NGP P record is closed. or example, if the L P record shows a 10/31/16 termination date, the effective date of the L shall be 11/1/ The BR shall create the L and N UP transaction on and the shared system maintainers shall accept and process the below two new P codes for use with P UP transactions and to identify a L and N in the P uxiliary file: shall be used to identify Ls; and T shall be used to identify Ns shall create two new contractor numbers and on incoming UP records. BR, P BR, P BR, P BR, P, R BR, P ontractor number shall be associated to incoming P UP records for application on the P uxiliary file ontractor number shall be associated to incoming P T UP records for application on the P uxiliary file. BR, P BR, P The shared system maintainers shall accept contractor number 11144, P code and source code 44 on the returned 03 trailer response The shared system maintainers shall accept contractor number 11145, P code T and source code 45 on the returned 03 trailer response , and the shared system maintainers, shall accept a 44 in the source code field on the UP and U/UT transactions for contractor BR, P

4 hared- ystem aintainers , and the shared system maintainer, shall accept a 44 in the source code field on the U/UT transactions for contractor B , and the shared system maintainers, shall accept a 45 in the source code field on the UP and U/UT transactions for contractor BR, P , and the shared system maintainer, shall accept a 45 in the source code field on the U/UT transactions for contractor The, and the shared system maintainers, shall only accept a Y alidity ndicator for UP transactions created by ontractor or ontractor BR, P shall only return a UP to if the P was originated by the s shall send a Y validity indicator for U transactions for ontractor and shall use the following address for contractor numbers and 11145: L and N P.O. Box Oklahoma ity, OK shall only allow ontractors and to add, update, or delete P records created by contractor shall only allow ontractors and to add, update, or delete P records created by contractor shall create and send a U transaction to the shared system maintainers that processed claims for each beneficiary when either an "add," "update," or "delete" transaction is received from contractor 11100, or contractor The ontractor Reporting of Operational orkload (RO) Report shall be updated to reflect pecial Project 7044 as "Liability edicare et-aside" and pecial Project number 7045 as "No-ault edicare et-aside." BR, P BR, P RO

5 hared- ystem aintainers The s, s and the designated shared system maintainers shall identify P savings for Ls and Ns under special project 7044 and 7045, as applicable, when L and N claims are processed. B P savings for special project 7044 shall be identified under the Liability column and savings for special project 7045 shall be identified under the No- ault column in the P avings Report and in RO. RO P claims shall be considered cost avoided when a claim is returned without payment because indicators indicate another insurer is primary to edicare shall create and use P savings type for No-ault and "L" for Liability when the claims process through post pay and posted to the P avings file for Ns and Ls shall apply the same P consistency edit codes that it currently applies for P (Liability) code L (numeric code 47) to P code The shall apply the same P consistency edit codes that it now applies for P (uto/no-ault) code (numeric code 14) to P code T making sure has the correct P record associated with the claim The s () shared system shall continue to accept claims with value code 47 and 14 for Part claims that may be reviewed against an open or T P auxiliary record The s (B) and shared systems shall continue to accept claims with insurance code 47 and 14 in association with an open or T P auxiliary record The s and s shall not make payment for those services related to the diagnosis code (or related within the family of diagnosis codes) associated with the open or T P auxiliary record when the claim s date of service is on or after

6 hared- ystem aintainers the P effective date. B The shall create a new P error code (P) that shall set when an incoming UP transaction with P ode "" or T" is submitted and the Beneficiary P uxiliary ile contains an open L" or P occurrence that has the same effective date and diagnosis code(s). This means the L or the N record cannot be created until the "L" or record is closed The maintainer shall create a new utilization error code (68) - L exists. edicare contractor payment not allowed." The maintainer shall create a new utilization error code (68) - "N exists. edicare contractor payment not allowed." shall set the new utilization error codes under the following conditions : B B B n open occurrence on the P uxiliary file exists with a P code or T and; edicare contractor attempts to pay the claim; and The diagnosis code(s) on the claim is/are related to the diagnosis code(s) on the open record. The two new 68 and 68 utilization error codes shall not set when the L or N P uxiliary record contains a termination date, no matter what the date of service is, so edicare can make a payment. B The shared systems shall accept both of the new error codes (68) and (68) when returned with an 08 trailer Upon receipt of the utilization error code, the shall deny all claims, detail line level only for Part B services, (including conditional payment claims) related to the diagnosis codes, or related within the family of diagnosis codes, on the open P

7 hared- ystem aintainers auxiliary file for P code or T when there is no termination date entered for the P or T record because funds are not exhausted. NOT: be returning the two new error codes with Trailer 39 to indicate which detail line(s) on the Part B or claim caused the error code to set. B Upon denying the claim, the and shared system maintainers shall create a 44 or 45 Payment enial ndicator, Non-payment/ Payment enial odes, in the header of the UP, UOP, U, U, UB, or U claims. Upon denying the claim, the (B), the s and shared systems shall: Populate an or T in the P code field; and reate a 44 or 45 in the UB and U claim header transaction as well as in the claim detail pay process field. Upon denying the claim, the () and shared system maintainer shall populate a 47 or 14 in the value code field The s and shared system maintainers shall apply laim djustment Reason ode (R) 201-(Patient is responsible for amount of this claim/service through 'set aside arrangement' or other agreement) with Group ode PR and edicare ummary Notice (N) message 29.33, defined below, when denying claims based on the open or T P auxiliary record The s and shared systems shall reflect R 201 and Group ode PR on outbound 837 claims and on 835 lectronic Remittance dvices (Rs) when there is an open or T P auxiliary record n addition to R 201 and Group ode PR, when denying a claim based upon the existence of an open or T P record, the and shall include the following Remittance dvice Remark odes (RRs) and N message as appropriate to the situation:

8 hared- ystem aintainers N723 Patient must use liability set aside (L) funds to pay for the medical service or item. B N724 Patient must use no-fault set-aside (N) funds to pay for the medical service or item. N Your claim has been denied by edicare because you may have funds set aside from your settlement to pay for your future medical expenses and prescription drug treatment related to your injury(ies). N u reclamación ha sido denegada por edicare porque usted podría sacar dinero de su convenio/acuerdo para pagar por sus futuros gastos médicos y su tratamiento con medicinas recetadas relacionadas a su lesión(es) shall ensure that the overrideable error code 68 and 68 may be overridden for payment by the shared system maintainers, and s, with override code N for claim lines or claims on which: auto/no-fault insurance set-asides diagnosis codes do not apply, or are not related, or liability insurance set-asides diagnosis codes do not apply, or are not related, or when the L and N benefits are exhausted/terminated per R or RR and payment information found on the incoming claim as cited in R shall allow for an override of error code 68 and 68 within the header of claims transaction sent to so that a secondary payment on a claim can be made when benefits are exhausted in the middle of a claim billing period. B hen, L or N benefits are terminated or exhausted during a provider stay or physician visit and the claim is not fully paid, the B

9 hared- ystem aintainers s, s and shared system maintainers shall make a residual payment on that claim by sending the primary payer amounts to the PPY module to calculate edicare s residual payment if such services are covered and otherwise reimbursable by edicare. NOT: R 9009 outlines policies for benefits exhausted that and the s shall follow for Ls and Ns. This means the residual payment indicators identified in R 9009 will apply as edicare payment may be made due to benefits being exhausted during a hospital stay or performed service. B s (B) and s shall override payable lines with override code N. NOT: Override code "N" is used where NGP No-fault and liability services are involved and the service is either: Not a covered service under the primary payer's plan; Not a covered diagnosis under the primary payer's plan; or Benefits have been exhausted under the primary payer's plan s () shall override payable claims with override code N f the () is attempting to allow payment on the claim, the () shall include an N on the 001 Total revenue charge line of the claim f there is an open GP record on, the P claim shall be denied as it should be sent to the primary insurer first if it was not done so already. NOT: shall use P error code 6803 first in this situation s () shall add 14, 15 or 47 with payment amount of $0 to, Liability or N claims when rejecting the claim due to an open record at. NOT: s shall also apply occurrence code 1,2,3,4 or 5, as applicable, with the effective date of the in the occurrence code date when cost avoiding the claim.

10 hared- ystem aintainers The omprehensive rror Rate Testing (RT) contractor shall accept the P codes (14) and L (47) within the claims resolution code field. B RT The s and designated, shared system maintainers shall send the P codes (14), (15), for, and L (47) to RT as necessary. RT s and shared systems shall make payment for those services related to the diagnosis codes associated with the closed "" or T P auxiliary record for covered and reimbursable services. NOT: shall not send a P error code in this situation where the record is closed or claims with dates of service between the, L or N effective and termination date, edicare shall make a payment for covered and reimbursable services. NOT: f there is an open GP record on, the P claim shall be denied as it should have been sent to the GP insurer first if it was not done so already and the copy book shall be updated to include the two (2) byte field named P Qualifier codes LT and P to populate the P Qualifier field for files sent to the B for generation of 270/271 to providers via T alerting them of the L and Ns s shall update their T-related documentation to reflect that P Qualifier LT means Litigation (Liability) and represents an L for provider education purposes. T, B s and s shall update their Trelated documentation to reflect that P Qualifier P means uto nsurance Policy (uto/no-ault) and represents a N for provider education purposes shall associate LT in the P Qualifier field with P type " for T processing. T shall associate P in the P Qualifier T

11 hared- ystem aintainers field with P type T" for T processing. B shall transmit the LT and/or P qualifier as part of its OB file exchanges with B and NG for T processing B and NG shall modify their systems to accept and allow in the two (2) byte field named P Qualifier the codes LT and P to populate the P Qualifier field B and NG shall accept the LT qualifier to denote a L P occurrence B and NG shall accept the P qualifier to denote a N P occurrence T shall transmit, in the B04 segment of the 270/271 interface, an insurance type LT, which indicates a L for P type code records received from T shall transmit, in the B04 segment of the 270/271 interface, an insurance type P, which indicates a N for P type code T records received from T shall continue to transmit an insurance type 47 on outbound 271 transactions in association with traditional Liability records (P type L on ) T shall continue to transmit an insurance type 14 on outbound 271 transactions in association with traditional uto/no-ault records (P type on ) shall continue to return alue ode 47 for P type code on the B and NG extract file under P ode shall continue to return alue ode 14 for P type code T on the B and NG extract file under P ode. T, B, NG B, NG B, NG B, NG T, B T, B T, B T, B The 1524 report shall also capture the N and L when the records are open in and

12 hared- ystem aintainers does not capture this information when the records are closed. B. PROR UTON TBL Number Requirement Responsibility LN rticle: provider education article related to this instruction will be available at Network-LN/LNattersrticles/ shortly after the R is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their eb sites and include information about it in a listserv message within 5 business days after receipt of the notification from announcing the availability of the article. n addition, the provider education article shall be included in the contractor's next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. B. UPPORTNG NORTON ection : Recommendations and supporting information associated with listed requirements: N/ "hould" denotes a recommendation. -Ref Requirement Number Recommendations or other supporting information: ection B: ll other recommendations and supporting information:. ONTT Pre-mplementation ontact(s): Richard azur, or richard.mazur2@cms.hhs.gov, Brian Pabst, or Brian.Pabst@cms.hhs.gov Post-mplementation ontact(s): ontact your ontracting Officer's Representative (OR).

13 . UNNG ection : or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTNT: 0